X-ray interpretation skills - KSU

X-ray Interpretation Skills Dr. Hisham Alsanawi Assistant Professor Medical Decision Making is a Triad History from patients/records

Physical Examination Confirming Studies Imaging, Labs, etc. Imaging

X-ray Ultrasound

CT Scan MRI Nuclear Medicine X-RAY

Radiation Source Patient Exposed

Capture Image Interpret Image X-RAY Ionizing Radiation Radiation damages cells

X-RAY Patient Blocks Transmission of Radiation Soft tissues Less Bones More

X-RAY Capture Image Films Digital X-RAY

Interpret Image Radiologist Orthopaedist X-RAY Best for:

Hard tissue Bones Often combined with other imaging OBJECTIVES Review a systematic approach to interpreting

orthopedic x-rays Review the language of fracture description ABCs APPROACH Pre ABC: identify pt, read provided info A

Adequacy Alignment B Bones

C Cartilage S Soft Tissues

Apply ABCs approach to every orthopedic film you evaluate ADEQUACY All x-rays should have an adequate number of views. Minimum of 2 viewsAP and lateral

3 views preferred Joint above and joint below All x-rays should have adequate penetration ALIGNMENT

Alignment: Anatomic relationship between bones on x-ray Bone alignment vs other side Bone alignment relative to proximal and distal bones

Normal x-rays should have normal alignment Fractures and dislocations may affect the alignment on the x-ray BONES 1. Identify bone

2. Examine the whole bone for 1. Discontinuity fractures 2. Change in bone shadow consistency change in density 3. Describe bone abnormality

1. Location 2. Shape CARTILAGE Cartilage joint spaces on x-rays

you cannot actually see cartilage on x-rays Widening of joint spaces signifies ligamentous injury and/or fractures Narrowing of joint spaces arthritis

SOFT TISSUES Soft tissues implies to look for soft tissue swelling and joint effusions These can be signs of Trauma occult fractures

Infection Tumors REVIEW: ABCs A Assess adequacy of x-ray which includes proper number of views

and penetration Assess alignment of x-rays B Examine bones throughout their entire length for fracture lines and/or distortions

C Examine cartilages (joint spaces) for widening S Assess soft tissues for swelling/effusions

EXAMPLE # 1 EXAMPLE # 1 This x-ray demonstrates a lateral elbow x-ray. There is swelling anteriorly which is displaced

known as a pathologic anterior fat pad sign There is swelling posteriorly known as a posterior fat pad sign Both of these are signs of an occult fracture although none are visualized on this x-ray Remember, soft tissue swelling can be a sign of


If you follow ABCs, you will notice there is are problems with alignment on this x-ray (A) (B)You will notice there are fracture lines through the 2nd, 3rd, and 4th metacarpals These are 2nd, 3rd, and 4th, midshaft metacarpal fractures.

A teaching point: Notice the ring on this film. Always remove rings of patients with fractured extremities because swelling may preclude removal later. LANGUAGE OF FRACTURES

Important for use to describe x-rays in medical terminology. Improves communication with orthopedic consultants LANGUAGE OF FRACTURES

Things you must describe (clinical and x-ray): Open vs Closed fracture Anatomic location of fracture Fracture line Relationship of fracture fragments Neurovascular status

OPEN VS CLOSED Must describe to a consultant if fracture is open or closed Closed fracture Simple fracture No open wounds of skin near fracture

Open fracture Compound fracture Cutaneous (open wounds) of skin near fracture site. Bone may protrude from skin Open fractures are open complete displaced and/or comminuted


Orthopedic emergency Requires emergency orthopedic consultation Bleeding must be controlled Management IV antibiotics

Tetanus prophylaxis Pain control Surgery for washout and reduction ANATOMIC LOCATION Describe the precise anatomic location of the

fracture Include if it is left or right sided bone Include name of bone Include location: ProximalMidDistal To aid in this, divide bone into 1/3rds

FOR EXAMPLE....WHERE IS THIS LOCATED? EXAMPLE This is a closed L distal femur fracture.

The main thing I want you to take from this example is the description of location ANATOMIC LOCATION Besides location, it is helpful to describe if the location of the fracture involves the joint space


Next, it is imperative to describe the type of fracture line There are several types of fracture lines FRACTURE LINES

FRACTURE LINES A is a transverse fracture B is an oblique fracture C is a spiral fracture D is a comminuted fracture There is also an impacted fracture where fracture ends are


Transverse fractures occur perpendicular to the long axis of the bone. To fully describe the fracture, this is a closed midshaft transverse humerus fracture. ANOTHER EXAMPLE OF FRACTURE

LINE ANS: SPIRAL FRACTURE Spiral fractures occur in a spiral fashion along the long axis of the bone They are usually caused by a rotational force

To fully describe the fracture, this is a closed distal spiral fracture of the fibula ONE MORE EXAMPLE ANS: COMMINUTED FRACTURE

Comminuted fractures are those with 2 or more bone fragments are present Sometimes difficult to appreciate on x-ray but will clearly show on CT scan To fully describe the fracture, this is a closed R comminuted intertrochanteric fracture

FRACTURE FRAGMENTS Terms to be familiar with when describing the relationship of fracture fragments Alignment Angulation

Apposition Displacement Bayonette apposition Distraction Dislocation

ALIGNMENT/ANGULATION Alignment is the relationship in the longitudinal axis of one bone to another Angulation is any deviation from normal alignment Angulation is described in degrees of angulation

of the distal fragment in relation to the proximal fragmentto measure angle draw lines through normal axis of bone and fracture fragment 20 DEGREES OF ANGULATION

OTHER TERMS Apposition: amount of end to end contact of the fracture fragments Displacement: use interchangeably with apposition Bayonette apposition: overlap of fracture fragments Distraction: displacement in the longitudinal axis of

the bones Dislocation: disruption of normal relationship of articular surfaces DESCRIBE FRACTURE FRAGMENTS

ANSWER This is a closed midshaft tibial fracture.But how do we describe the fragments? This is an example of partial apposition; note part of the fracture fragments are touching each other Alternatively you can describe this as displaced 1/3 the

thickness of the bone Remember aposition and displacement are interchangeablewe tend to describe displacement Final answer: Closed midshaft tibial fracture with moderate (33%) displacement

ANOTHER ONE ANSWER There are 2 fractures on this film Closed distal radius fracture with complete displacement. Also there is an ulnar styloid fracture which is also

displaced The displacement is especially prominent on the lateral view highlighting the importance of multiple views. There may be intra-articular involvement as joint space is close by Remember, remove all jewelry from extremity fractures


Note the dislocation on the previous slide; the articular surfaces of the knee no longer maintain their normal relationship Dislocations are named by the positioin of the distal segemnt This is an Anterior knee dislocation

NEUROVASCULAR STATUS Finally when communicating a fracture, you will want to describe if the patient has any neurovascular deficits This is determined clinically

LANGUAUGE OF FRACTURES To review, when seeing a patient with a fracture and the x-ray, describe the following: Open vs closed fracture Anatomic location of fracture (distal, mid, proximal)

and if fracture is intra-articular Fracture line (transverse, oblique, spiral, comminuted) Relationship of fracture fragments (angulation, displacement, dislocation, etc) Neurovascular status

DESCRIBE THIS R MIDDLE PHALANX FRACTURE ANSWER Oblique fracture of midshaft of R 4 th middle phalanx with minimal displacement and no

angulation Remember to comment if open vs closed & neurovascular status DESCRIBE TO ORTHO ATTENDING

ANSWER This one is a bit more challenging! R midshaft tibia fracture displaced the thickness of the bone without angulation; also there is bayonette appositioning of the fracture

fragments R midshaft fibular fracture with complete displacement and Also comment if the fracture is open vs closed & neurovascular status

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